INSTITUTIONAL REVIEW BOARD FOR THE PROTECTION OF HUMAN SUBJECTS IN RESEARCH
Consent Form Template Instructions
4/15/2016 Version

The consent form should be written at no greater than an eighth grade reading
level and using lay person language (i.e., no complex scientific or medical terms).
Avoid dense paragraphs using long sentences and large words. Use bullets,
headings, and white space wherever possible to facilitate understanding.

In the following template:
 Headings should be kept as part of the consent form unless otherwise indicated.
 Instructions are in red. Remove these instructions from your final document.
 Suggested wording is in plain font. This information should be
edited/deleted/revised to accurately represent participation in your study.
Please carefully review all the language to ensure correct information specific to
your study is relayed to potential participants.

The consent form should be written in the second person, e.g., “You will be asked
to….”

If the consent form is for the involvement of children in a study, “you” should be
replaced with “your child.”

Pages of the consent form should be numbered.

If the IRB requires the researcher to obtain signed consent forms from participants,
the researcher must keep the signed consent form as part of the research files for a
minimum of three years after the end of the study, and provide a copy to each
participant.

Staff in Research Integrity Services office can provide assistance in developing
consent forms or pre-review your draft consent form at anytime. Please email Julie
Simpson (or call @ 603/862-2003) if you need help with developing consent forms.
CONSENT FORM FOR PARTICIPATION IN A RESEARCH STUDY
RESEARCHER AND TITLE OF STUDY
Identify yourself (e.g., My name is Mary Jones and I am an undergraduate at the University
of New Hampshire) and the title of the study.
WHAT IS THE PURPOSE OF THIS FORM?
This consent form describes the research study and helps you to decide if you want to
participate. It provides important information about what you will be asked to do in the
study, about the risks and benefits of participating in the study, and about your rights as a
research participant. You should:
 Read the information in this document carefully.
 Ask the research personnel any questions, particularly if you do not understand
something.
 Not agree to participate until all your questions have been answered, or until you are
sure that you want to.
 Understand that your participation in this study involves you (describe participation
[e.g., taking a survey]) that will last about (explain anticipated time commitment).
WHAT IS THE PURPOSE OF THIS STUDY?
State the purpose of the research in as few words as necessary and in a manner that
participants will be able to understand. Usually, this can be accomplished in one sentence,
e.g., "The purpose of this research is....."
State the anticipated number of participants who will be involved in the study.
Where appropriate, state that participants must be at least 18 years old to participate in the
study.
WHAT DOES YOUR PARTICIPATION IN THIS STUDY INVOLVE?
Describe the research in a manner that will ensure that participants understand what they
are being asked to do. This will probably involve a short paragraph, depending on the
complexity of the research, and should include sentences explaining:
 Detailed descriptions of procedures to be followed/tasks involved, and
 Expected length of time of a participant's involvement.
WHAT ARE THE POSSIBLE RISKS OF PARTICIPATING IN THIS STUDY?
Describe the risks which participants may reasonably expect from the research. The
information should reflect that provided in the narrative. If the study presents only minimal
risk, state this (e.g., “Participation in this study is expected to present minimal risk to you.”
WHAT HAPPENS IF YOU GET SICK OR HURT FROM TAKING PART IN THIS STUDY?
Include this section (including title) only if applicable.
If you are injured or require medical treatment, you may seek treatment from your primary
care provider or, if eligible, from University Health Services. The University of New
Hampshire is not responsible for the cost of any care required as a result of your
participation in this study.
1
WHAT ARE THE POSSIBLE BENEFITS OF PARTICIPATING IN THIS STUDY?
Describe the potential benefits that participants may reasonably expect from participating in
the research. If there are no direct benefits to participants, state this and explain the
benefits of the knowledge to be gained through the study. (Money, course credit, raffle
prizes, etc. are considered compensation, not benefits, and thus should not be included in
this section [they should be described in Compensation section of the form].)
IF YOU CHOOSE TO PARTICIPATE IN THIS STUDY, WILL IT COST YOU ANYTHING?
Include this section (including title) only if applicable. Describe any costs to participants to
participate in the study.
WILL YOU RECEIVE ANY COMPENSATION FOR PARTICIPATING IN THIS STUDY?
State whether compensation will be provided for participating in this study. If compensation
will be provided, provide all the relevant details, including conditions that need to be met to
receive the compensation.
DO YOU HAVE TO TAKE PART IN THIS STUDY?
Taking part in this study is completely voluntary. You may choose not to take part at all. If
you agree to participate, you may refuse to answer any question. If you decide not to
participate, you will not be penalized or lose any benefits for which you would otherwise
qualify (modify this sentence if there are conditions to receive compensation/incentive).
CAN YOU WITHDRAW FROM THIS STUDY?
If you agree to participate in this study and you then change your mind, you may stop
participating at any time. Any data collected as part of your participation will remain part of
the study records (modify this sentence where applicable). If you decide to stop
participating at any time, you will not be penalized or lose any benefits for which you would
otherwise qualify (modify this sentence if there are conditions to receive
compensation/incentive).
WHAT ALTERNATIVES ARE AVAILABLE IF YOU DO NOT WANT TO PARTICIPATE IN THIS
STUDY?
Include this section (including title) only if the study takes place in a classroom setting and
extra credit is awarded. Revise as necessary to fit the specifics of the study.
Participation in this study is not part of your required coursework. If you want to earn the
extra credit offered for participating in the study but you do not want to participate in the
study, the alternative assignment for this study is (describe the alternative assignment).
HOW WILL THE CONFIDENTIALITY OF YOUR RECORDS BE PROTECTED?
I plan to maintain the confidentiality of all data and records associated with your
participation in this research.
If your study involves personally-identifiable information, include the following sentence and
bullets.
There are, however, rare instances when I may be required to share personally-identifiable
information with the following:
 Officials at the University of New Hampshire,
 The sponsor(s), or
2

Regulatory and oversight government agencies.
If your study may lead to disclosure of information covered by New Hampshire mandatory
reporting laws, such as suspected child abuse and/or neglect, or Federal laws relating to
sexual harassment and violence include the following sentence and applicable bulleted
language. [See the document, Information Individuals in New Hampshire are Legally
Required to Report at http://unh.edu/research/irb-application-resources for more
information.]
I am also required by law to report certain information:
 To government and/or law enforcement officials (e.g., child abuse, threatened
violence against self or others, communicable diseases), or
 To appropriate UNH authorities (e.g., disclosures involving Sexual Violence - which
includes sexual harassment, sexual assault, unwanted sexual contact, sexual
misconduct, domestic violence, relationship abuse, stalking [including cyberstalking] and dating violence - must be reported to the UNH Title IX Coordinator or
UNH Police).
If your study involves transmitting data via email or the web [e.g., web-based survey],
include the following sentence.
Further, any communication via the internet poses minimal risk of a breach of
confidentiality.
If your study involves focus groups, include the following sentence.
While I plan to maintain confidentiality of your responses, other focus group participants
may repeat responses outside the focus group setting.
To help protect the confidentiality of your information, (address the following: (1) explain
procedures in place to protect confidentiality of study data; (2) identify everyone named in
the application with access to the data; if applicant is a student, the faculty advisor must
have access to data; (3) explain if de-identified data may be shared with other researchers;
(4) if audio and/or videorecording, explain how and where recordings will be stored, and
what will happen to them during and after the study [e.g., transcribed and then
destroyed].) I will report the data (explain how data will be reported [e.g., in aggregate,
using pseudonyms]). The results may be used in reports, presentations, and publications
(modify this sentence to reflect how the results may be used).
WHOM TO CONTACT IF YOU HAVE QUESTIONS ABOUT THIS STUDY
If you have any questions pertaining to the research you can contact (insert researcher's
name and contact information and/or advisor's name and contact information) to discuss
them.
If you have questions about your rights as a research subject you can contact Dr. Julie
Simpson in UNH Research Integrity Services, 603/862-2003 or Julie.simpson@unh.edu to
discuss them.
If the consent document will be mailed and returned, include the sentences in this
paragraph.
I have enclosed two copies of this letter. Please sign one indicating your choice and return
in the enclosed envelope. The other copy is for your records.
3
If the consent document is for participation only in a non-web-based survey (see below the
format for web-based surveys), remove the participant signature block below (the IRB
generally does not require signed consent forms for surveys).
Yes, I, __________________________consent/agree to participate in this research project.
No, I, __________________________do not consent/agree to participate in this research
project.
___________________________
Signature
__________________
Date
If the consent information is for participation only in a web-based survey, (e.g., using
Qualtrics), replace the participant signature block above with the following format for
participants to give consent or decline participation.
o
o
Click here if you consent to participate in the research study.
Click here if you decline to participate in the research study.
4